Colchester General Hospital signed up to Patient Safety First in 2008. One of the key interventions they have targeted is the ventilator care bundle, which is part of the critical care intervention that aims to reduce the incidence of ventilator-associated pneumonia.
Since 2004 Colchester Critical Care had been undertaking a daily audit concerning compliance of the four aspects that comprised the ventilator care bundle including:
- Semi-recumbent positioning
- Daily sedation hold
- Peptic ulcer prophylaxis
- Deep vein thrombosis prophylaxis
Alison Ruffell, a nurse in the Critical Care Unit at Colchester says: “Our results were impressive as, for the majority of the time, compliance was recorded at 100 per cent. At this stage we were not formally noting incidences of ventilator-associated pneumonia. However, our involvement in Patient Safety First prompted us to re-visit our current work on the prevention of VAP.”
To ensure that patient safety was a priority the following staff were appointed to ensure that patient safety was a priority:
- Consultant microbiologist
- Consultant anaesthetist
- Band 7 Sister Critical Care
Ms Ruffell says: “The project commenced with a paper being distributed to senior management outlining the aims of the project. Within a ten-day period over 90 per cent of nursing staff, physiotherapists and medical staff were individually briefed. Clear guidelines were made available at every bed space outlining the inclusion and exclusion criteria for each aspect of the care bundle.”
At this stage, in accordance with NICE Guidelines, they introduced oral chlorhexidine as the fifth component in their care bundle. Ms Ruffell adds: “The project commenced in mid January and it was clearly apparent within one week that the accuracy of our previous audit could be disputed as our compliance with the new audit was only around 80 per cent.”
The two main areas of non-compliance were:
1. Semi-recumbent positioning – nurses were not able to visualise the 30 degree angle and as a result Perspex templates were designed and manufactured to highlight the correct angle required.
2. Sedation hold - Towards the end of each night shift the nurse co-ordinator and critical care anaesthetist now identify the patients who fulfil the inclusion criteria. These are highlighted at both nursing and medical handovers in the morning and a sedation hold for relevant patients takes place at 8.30 am.
Incidences of VAP
As the aim of the ventilator bundle was to reduce incidences of VAP it was important for the team to know their VAP rates. However, it was decided that there was insufficient time or personnel available to look back at previous patient data so from the commencement of the project they decided to use the Johanson criteria (as recommended at the American Thoracic Society Consensus Conference in 2004) to identify VAP.
Ms Ruffell says: “Incidences of VAP are being investigated through root cause analysis in tandem with ventilator care bundle compliance. From the commencement of the project there have been five confirmed cases of VAP but we are currently ascertaining a more robust method to ensure cases are identified in a timely manner.”
Both to ensure that momentum is maintained and to demonstrate the team’s ongoing commitment to the Patient Safety First campaign, they have utilised a number of forums to update current progress with this project. A formal presentation was delivered to over 60 medical staff at a multi-disciplinary audit day. The trust board, the Patient Safety Committee and our Critical Care Network are regularly informed of progress and current audit figures are displayed in the staff rest room.
“The current progress with this project has exceeded our expectations,” continues Ms Ruffell. “There is no doubt that support at trust board level in conjunction with commitment from all members of our critical care multi-disciplinary team is the main reason for this. The input by individuals who are not primarily trained in critical care has enabled us to appreciate how our efforts not only benefit our own patients but may be utilised by the Patient Safety First campaign to a wider audience throughout the UK and beyond.”
For more information visit www.patientsafetyfirst.nhs.uk
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Patient Safety First